Kaiser covers the sleeve?

Mandyplus2 ..
on 11/14/09 3:36 pm - GA
At my seminar today, the surgeon said that Kaiser covers VSG.

So, for those with Kaiser, I found this link stating their criteria for referral:
http://www.permanente.net/homepage/kaiser/pdf/38105.pdf

But I need to know how many years of documentation they need at a particular BMI. For instance, Aetna (my insurer) wants two years of documented proof at your qualifying BMI.

Also, that document is their "referral criteria." Do they have a separate qualifying criteria to meet? Or is this it?

My husband's company has open enrollment at the beginning of the year and we can switch from Aetna to Kaiser but I need to make sure that it would be worth it for me based on my medical history. I know Aetna has approved some VSGs but I think it's still rare that they will. The surgeon today said he has never had Aetna approve a single VSG so far, even when his office did appeals and he did a peer-to-peer with Aetna.

Oh, great, I just noticed this part:
The patient must be under the care of a PMG
physician for an appropriate period of time for the
physician to be familiar with the patient's medical,
social and psychological status prior to referral.


Well, geez, what do they consider an appropriate period of time? Ugh, this is all so discouraging. Mexico is looking better and better.
thereason79
on 11/14/09 3:57 pm
Hi Mandy,

Yes, Kaiser does cover the sleeve. That was my reason to switch my insurance provider when I had wasted almost two years trying to get qualified with HealthNet, as it seems to be the case with Aetha for you. In the end, they decided I did not have a medical reason for VSG, which I later came to find out was not the truth (asthma).

The process at Kaiser is lengthy, but the staff, in fact the whole team runs like a well tuned machine. They are coordinated, and require you to attend different workshops, and such. In the end, you come out a better informed patient before getting surgery.

I'm three days out, and very happy with the team here in NorCal. They do cover it, but you have to make a case for it, but honestly, in the end, if like me, that's what you feel is the right surgery for you, they will respect your decision instead of pushing you towards bypass (which happened with me and I still got sleeved!).
Mandyplus2 ..
on 11/14/09 4:43 pm - GA
Thank you for the info! You said it's a lengthy process...can you tell me about how long the process took?
phred
on 11/14/09 5:45 pm - CO

Here, in Colorado, it took a year from starting the weight loss journey until I got my sleeve.  I attended a 7 week "Weight Connections" class.

Then had once a month sessions with the weight loss counselor for about 5 months, then took a 12 week "Surgical Connections" class.

About a month later (after a psych eval), I got my sleeve.

This was in October of '08.  Since then I have attended once a month sessions with the weight loss counselor.

HTH,

Fred

  If it feels good, do it!  And if it smells good, eat it!

SmileyGael
on 11/14/09 6:04 pm
Hi-jack....Lookie there!  Mr.Fred has a smilin face!  Good to see you!


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Laura R.
on 11/14/09 6:02 pm, edited 11/14/09 6:03 pm
I didn't have to demonstrate any history at a certain BMI or above. Just met the minimums (and then some).

I got the sleeve with Kaiser although it wasn't officially offered as an option. All the literature and pre-surgeon appointments I had discussed only band and RNY. It was my surgeon who looked at my medical history (I've had three prior abdominal area surgeries) and suggested doing the sleeve because of scarring interference concerns.

The process, no matter which procedure, takes most about a year in Northern Cal, I hear. (Although if you cram, you might be able to do it in less time.) There was a multi-week info/support class, an orientation, a nutrition class (1/2 day), a lifestyle class (1/2 day), dr's appointment for a referral, obgyn appointment (mandatory for the referral), psych eval appointment ... and then the multiple surgeon appointments as I prepped.

Good luck!
 *high* *wls date* *current* *dr's goal* *mine*
       320         293            214          190           170    
SmileyGael
on 11/14/09 6:22 pm

Hey Laura, I just had my psych eval friday in Fremont.  Dr Hahn has already emailed me saying I can get a VSG...So now I wait for a date...

Ok Mandy, here is my experience...Also you can read my profile to see how long, and why its taken 3yrs...

Anyhoo, we switched to Kaiser cause it was the cheapest ins. offered.  I asked my PCP for a referral to the Bariactric program, and she referred me that day.

I got an appt. for the orientation meeting Nov or Dec 2008.

I got an appt. for a surgical consult for January 2009.  At that appt. I was told to lose 10% (30lbs.)  We are required to call in our wt. every month

  Since the VSG wasn't offered until very recently, I didn't do the psych eval till yesterday.  Now I wait for a date..

I didn't have to attend any "classes" for anything.

I've heard of folks speeding the process along by losing the 10% fast.  Especially if "classes" aren't required...

So all in all, Ya, its taken me a year, but remember, the VSG was not an option so I took my time, hoping it would be offered eventually.

Many Kaisers offer the VSG across the country, just depends on the area...

The main thing is to get the referral to the Bariactric program, and YOUR Kaiser will tell you all the requirements...

I have to tell you that we never cared for Kaiser.  Bad past experiences.  Iam SO impressed with the changes they have made, and really like Kaiser now.  They are so darn organized!

Hope this helps!


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Mandyplus2 ..
on 11/14/09 6:52 pm - GA
That is so funny because I was just telling my mom today that I HATED having Kaiser many years ago. It was the worst! I felt so controlled, like I had ZERO choices of my own (treatment, doctors, etc). They would just tell me how everything was going to be, who to go see, what they would do, etc.

I believe my mom has Kaiser now, or had it until she recently retired, and she loved it. I am glad to hear they have changed.

Truthfully, I'm not a fan of HMOs in general, but what can ya' do.
Jen C.
on 11/14/09 7:22 pm
In Northern California the whole process takes a year- from the day you first ask for a referral to the day you have surgery. Getting approved is fairly easy if you meet the BMI requirements. You don't have to prove how long you have been at the weight and you don't need to document previous weight loss attempts.

Kaiser is a low stress way to go, you don't need to deal with appeals and a lot of requirements, you just need to be patient with their process. Most people lose weight on their own during that year while they are waiting which helps make the surgery safer and the recovery easier.
 
Height: 5'7"     Join US On The VSG Maintenance Group Forum!!  
                          http://www.obesityhelp.com/group/VSGM/discussion/

Laura R.
on 11/14/09 8:16 pm
While I was frustrated and impatient during the first months of the process, I am now SO grateful for the Kaiser hoops, I can't offer enough praise.

They do their darndest to inform you and to ease you into the wls lifestyle. I read about folks who had little pre-op prep, and I think, "Wow, the transition to the post-op life must be overwhelming for you." I'd already spent months weaning myself off my great obsession -- bread items. I'd pared down portions, started working with the food scale and the food journal. etc. ... I was one of those folks who had complications -- and even That I was somewhat prepared to deal with because of the Kaiser program. Now that I'm a 'regular' post-op gal, I feel confident moving forward. I hope you have the same (minus the complications) experience!
 *high* *wls date* *current* *dr's goal* *mine*
       320         293            214          190           170    
thereason79
on 11/14/09 8:20 pm
I have to second what everyone else said here about Kaiser. They were definitely not my first choice, I was very happy with HealthNet, but they denied VGS, and after my appeal, I was denied again. I wasted about two years with them, and finally went back to Kaiser. A a former member, I've been very impressed with the changes they have made for a HMO. I had my own private room, and the medical staff were just great during my recovery.

The process does take an year with the orientation, lifestyle classes and such. Please do take advantage of these options, looking back now I'm glad they held me accountable for the things I needed to do. I tried to use my gallstones as an excuse to try to expedite my surgery date, but they did not fall for it, and in the end I had to lose the required 10% pre-surgery weight.

If you are able to lose your 10% weight, from your weigh in day, the whole process will take less than a year (at least that is the case here in Northern California). Good luck to you, and again, I agree with other posters that Kaiser's process for VGS is much easier.
Mandyplus2 ..
on 11/15/09 6:38 am, edited 11/15/09 6:43 am - GA
So they require everyone to lose 10% of their weight? Do they still go by the starting weight, since that would drop me below the 40 BMI?

Oh also, with Kaiser, can I still go to any Emergency Room? I have bad back problems and gall bladder problems that have sent me to the ER twice in the past 6 months.

I talked to DH about changing insurance to Kaiser. We really really love our pediatrician that we have and I hate to lose her (I drive 45 minutes just to take the kids to her, that's how much I love her!), but he said we can always switch back to Aetna eventually if we want.

(deactivated member)
on 11/15/09 8:18 am - Woodbridge, VA
Is your insurance through your employer or through your husband's employer? Is there a way you can get Kaiser for yourself through your employer and keep your family on another insurance through his employer? Come January, my husband and I will be on different insurances through our own employers - much more affordable in our case.
Mandyplus2 ..
on 11/15/09 8:36 am - GA
I am a SAHM so it's through my husband's employer.